What is the optimal management for patients with acute low back pain in the primary care setting?
EXCELLENT/GOOD EVIDENCEInitial clinical assessment should focus on finding "red flags"(i.e. clues suggesting fracture, tumour, infection, or cauda equina syndrome). Red flags include a history of cancer, weight loss, I.V. drug use, U.T.I., pain increased by rest, fever, bladder dysfunction, major limb motor weakness, and saddle anaesthesia. If initial assessment shows no suspicion of "red flags" the goals are to control symptoms and recommended activity modifications. For most patients, aerobic activities that minimally stress the back (walking, biking, or swimming) can be started during the first 2 weeks. If symptoms persist longer than 1 month, conditioning exercises for back extensors may be helpful. Massage, ice, heat, ultrasound, cutaneous laser, and electrical stimulation have not been shown to be helpful. Transcutaneous Electrical Nerve Stimulation (TENS) is not recommended. Muscle relaxants, opiods, steroids, colchicine, and antidepressants are not recommended.
FAIR EVIDENCEBed rest for more than 4 days is contraindicated. Spinal manipulation can be helpful for patients without radiculopathy when used in the first month.
CONSENSUSNo laboratory or x-ray examinations are necessary for the typical patient with no "red flags" If the pain causes activity limitations for more than 1 month even without "red flags" specialist referrals may be considered. Plain x-rays are only recommended within the first month of symptoms if "red flags" are present. Oblique views are not recommended. If plain x-rays are negative or "red flags" are found, CT or MRI may be helpful. A bone scan is recommended when spinal tumour infection, or occult fracture is suspected; bone scan should not be done during pregnancy. CT, MRI, myelography, or CT-myelography and/ or consultation with an appropriate specialist is recommended when clinical findings strongly suggest tumour, infection, fracture, or space-occupying lesions of the spine.
backpain links: http://hsl.mcmaster.ca/tomflem/backpain.html
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